toxic dye concerns for angioplsty

[marlinfshr]

To start with I'm not sure if this is in the correct area but it does concern my kidneys and I am currently on CAPD with 2 manual exchanges daily.

I went to see the cardiologist with the transplant team yesterday to give the final clearance to put me "active" on the list. It's been a year since my heart attack and stent placement and being on plavix. Well, I feel fine and everything sounds right EXCEPT for an early heartbeat so she did an EKG. It shows a slight dip in a spot which wasn't there last year and she is concerned that my artery or a stent may be clogging up again. So they called my regular cardiologist for me to see ASAP. I kind of wish he was a little bit more concerned when he felt my early beat back in January instead of just shrugging it off as a non-issue. That way if anything needs to be done I could of had it done in time for me to go to work this year.

Last year I had to quit my job and career because of this mess. My heart attack happened in April, right before my working season would have started and I am just getting ready to get my business going again cleaning boats as well as working as a sportfishing mate again (though part time on private boat) because with only 2 short manual exchanges a day I can and intend to get my life back. Now I'm worried that I'll be back in recovery stage for the season and that this time my kidneys might fail completely, making me lose all freedom.

See, it was the dye that put me here. My kidneys were weekend back in 99 due to chemo and my creatinine had been in the 3.5 to 4 range for years. Then I had a heart attack and they needed to place 3 stents. They knew the dye was going to damage me so they placed a temp catheter in my groin and started dialysis right away. They did what they had to do as I was having a heart attack so I don't think another option, if available, would have been a good idea.

My question is, if my artery's are blocked and I have to go through that again is there another type of dye (less toxic) that they can use? Are there any drugs they can give me beforehand to protect the kidneys from the dye? Perhaps I won't even need this done because it is nothing, or perhaps they can just up the dose of blood thinners, or perhaps something else---I don't know. Just trying to get as much info as I can so I can really see my options.

I am a bit worried as I am looking forward to returning to work, especially since it is what I love to do. The dye last year took my creatinine to 8.5 and since then it has gone back down to 5.3. I still make plenty of urine and my KTV with only 2 exchanges was 4.3 last time and my hemoglobin has steadily climed from a low of 8 right after the stents were placed to 14.5 a couple month's ago and has been holding there and I have never needed any medication to help it. So I'm very concerned that the dye---if I need another angioplasty---will weaken my kidneys to the point of making me anemic, taking away my pee and making me do the complete 4 exchanges which in that case I will not be able to return to my type of work.

[amanda100wilson]

I strongly recommend that you discuss this with your doctor before they carry out this procedure.

[noahvale]

*

[Michael Murphy]

18 months ago about 6 months before I started Dialysis i was in a car accident and suffered a massive rotator cuff tear in my reign shoulder.  They felt I needed to have a angiogram prior to the surgery.  My cardiologist picked the same surgeon who did my 6 stents 65 years prior to the current angiogram.  All I remember is the surgeon running around like a kid on Christmas showing every one my X-rays as he said take with "i think" 20 cc of dye.  What I learned is that a good or team can do the procedures with a small amount of dye.
A test after showed no effect on my kidneys.  I am a PKD patient and had delayed dialysis for several years and this procedure was not the reason I started dialysis.  I had changed my diet and lost 50 pounds to delay dialysis. 

[obsidianom]

(This is for you NoahVale. ---On a wing and a Prayer)    This may help. It was from 2011.  It seems worth a try.     American Journal of Cardiology  July 2011


  Short term, high-dose Atorvastatin pretreatment to prevent contrast-induced nephropathy in patients with acute coronary syndromes undergoing percutaneous coronary intervention (from the ARMYDA-CIN [atorvastatin for reduction of myocardial damage during angioplasty--contrast-induced nephropathy] trial.

Patti G1, Ricottini E, Nusca A, Colonna G, Pasceri V, D'Ambrosio A, Montinaro A, Di Sciascio G.


Contrast-induced nephropathy (CIN) impairs clinical outcome in patients undergoing angiographic procedures. The aim of this study was to investigate whether short-term high-dose atorvastatin load decreases the incidence of CIN after percutaneous coronary intervention (PCI). Statin-naive patients with acute coronary syndrome undergoing PCI (n = 241) randomly received atorvastatin (80 mg 12 hours before intervention with another 40-mg preprocedure dose, n = 120) or placebo (n = 121). All patients had long-term atorvastatin treatment thereafter (40 mg/day). Primary end point was incidence of CIN defined as postintervention increase in serum creatinine ≥0.5 mg/dl or >25% from baseline. Five percent of patients in the atorvastatin arm developed CIN versus 13.2% of those in the placebo arm (p = 0.046). In the atorvastatin group, postprocedure serum creatinine was significantly lower (1.06 ± 0.35 vs 1.12 ± 0.27 mg/dl in placebo, p = 0.01), creatinine clearance was decreased (80.1 ± 32.2 vs 72.0 ± 26.6 ml/min, p = 0.034), and C-reactive protein peak levels after intervention were decreased (8.4 ± 10.5 vs 13.1 ± 20.8 mg/l, p = 0.01). Multivariable analysis showed that atorvastatin pretreatment was independently associated with a decreased risk of CIN (odds ratios 0.34, 95% confidence interval 0.12 to 0.97, p = 0.043). Prevention of CIN with atorvastatin was paralleled by a shorter hospital stay (p = 0.007). In conclusion, short-term pretreatment with high-dose atorvastatin load prevents CIN and shortens hospital stay in patients with acute coronary syndrome undergoing PCI; anti-inflammatory effects may be involved in this renal protection. These results lend further support to early use of high-dose statins as adjuvant pharmacologic therapy before percutaneous coronary revascularization.

[Hemodoc]

To start with I'm not sure if this is in the correct area but it does concern my kidneys and I am currently on CAPD with 2 manual exchanges daily.

I went to see the cardiologist with the transplant team yesterday to give the final clearance to put me "active" on the list. It's been a year since my heart attack and stent placement and being on plavix. Well, I feel fine and everything sounds right EXCEPT for an early heartbeat so she did an EKG. It shows a slight dip in a spot which wasn't there last year and she is concerned that my artery or a stent may be clogging up again. So they called my regular cardiologist for me to see ASAP. I kind of wish he was a little bit more concerned when he felt my early beat back in January instead of just shrugging it off as a non-issue. That way if anything needs to be done I could of had it done in time for me to go to work this year.

Last year I had to quit my job and career because of this mess. My heart attack happened in April, right before my working season would have started and I am just getting ready to get my business going again cleaning boats as well as working as a sportfishing mate again (though part time on private boat) because with only 2 short manual exchanges a day I can and intend to get my life back. Now I'm worried that I'll be back in recovery stage for the season and that this time my kidneys might fail completely, making me lose all freedom.

See, it was the dye that put me here. My kidneys were weekend back in 99 due to chemo and my creatinine had been in the 3.5 to 4 range for years. Then I had a heart attack and they needed to place 3 stents. They knew the dye was going to damage me so they placed a temp catheter in my groin and started dialysis right away. They did what they had to do as I was having a heart attack so I don't think another option, if available, would have been a good idea.

My question is, if my artery's are blocked and I have to go through that again is there another type of dye (less toxic) that they can use? Are there any drugs they can give me beforehand to protect the kidneys from the dye? Perhaps I won't even need this done because it is nothing, or perhaps they can just up the dose of blood thinners, or perhaps something else---I don't know. Just trying to get as much info as I can so I can really see my options.

I am a bit worried as I am looking forward to returning to work, especially since it is what I love to do. The dye last year took my creatinine to 8.5 and since then it has gone back down to 5.3. I still make plenty of urine and my KTV with only 2 exchanges was 4.3 last time and my hemoglobin has steadily climed from a low of 8 right after the stents were placed to 14.5 a couple month's ago and has been holding there and I have never needed any medication to help it. So I'm very concerned that the dye---if I need another angioplasty---will weaken my kidneys to the point of making me anemic, taking away my pee and making me do the complete 4 exchanges which in that case I will not be able to return to my type of work.

Yes, there are methods of reducing risk from the dye, in general the results are not as satisfying as we would hope. However, the first thing you will have to do is to convince the doctors that you should have this as a consideration. Most doctors look at a dialysis patient and right off any residual renal function not understanding how dreadfully important it really is. Most docs don't understand some of us on dialysis still urinate and at times, in large quantities.

I would start with your nephrologist and hopefully he is aware of how important it is and then have him discuss directly with the cardiologist why taking appropriate precautions is worthwhile. Discuss residual renal function with your cardiologist. It may be something that they had not thought about before.

In the long run, it is a very likely outcome that your kidneys will take another hit. If transplant is your preferred choice, then that may be part of the price of the evaluation. I would definitely make sure that the transplant team is seriously interested in the transplant. Get them to give you a percent chance of transplant, estimate obviously, before you do consider the angiogram if you still have significant amounts of residual urine function.

Yes, it is an important issue and you will need to have discussions with all of your medical teams involved so that you have the best information before you make your informed decision on what your best options are. If your chance of transplant is slim, then you may be placing yourself at undo risk by further damaging your residual urinary function.

Sorry, not knowing all of your facts makes it difficult to know for certain where your benefits and risks fall out. I would certainly bring up these questions, search the internet for the methods of dealing with dye injuries and techniques to prevent it so that you are well informed when discussing this with all of your medical teams. That will give you a higher stake in the decision rounds. By all means, ask the questions because you may end up with further complications from the angiogram which is simply a fact of life with any medical procedure. If you understand all the issues involved to your satisfaction, then that is the time to make a final decision, but not before.

I hope that this helps and all works well.

[marlinfshr]

Thank's. Yes, this info does help.
Believe me, I intend to ask, ask and ask. I'm also hoping that it isn't blocked as I feel great. But I need to prepare and study my options if it is determined that this is the case. The one big difference is that last year I was having a heart attack. What needed to be done needed to be done right at that time as there was no time to wait. At least this time, if it is recommended/determined that that is what I need, perhaps I can be prepared for it.

As far as the transplant, sometimes I wonder if I really have bad kidneys as I don't have any symptoms and feel great. All my numbers are right where they should be and I have no fluid restrictions and eat what I want, many times food that isn't really renal friendly but my numbers are great. Now in regards to my numbers, even though everything comes back great, I'm not anemic and still pee everything I drink with it still coming out yellow if I have let it build up a while, my creatinine is still elevated (5.?) and my BUN is still not good at 40 which shows I'm just in some stage of denial. I am accruing time on the transplant list but am not in active status until the transplant center cardiologist clears me. They wanted to wait until I have been on Plavix for a year. That's what yesterdays appointment was about.

I would like to have a transplant since it will get me off this dialysis and I could return to a traveling job up and down the coast again. I'm only 45 (well almost 46) so I intend to be here for a while and understand that in reality, whenever I do get a transplant I may get off dialysis for now but this won't be my last time having it--based on average time a transplant will last.

I guess it's time to study my options just in case but hope this is nothing major. I guess I'll find out soon.

[Hemodoc]

Thank's. Yes, this info does help.
Believe me, I intend to ask, ask and ask. I'm also hoping that it isn't blocked as I feel great. But I need to prepare and study my options if it is determined that this is the case. The one big difference is that last year I was having a heart attack. What needed to be done needed to be done right at that time as there was no time to wait. At least this time, if it is recommended/determined that that is what I need, perhaps I can be prepared for it.

As far as the transplant, sometimes I wonder if I really have bad kidneys as I don't have any symptoms and feel great. All my numbers are right where they should be and I have no fluid restrictions and eat what I want, many times food that isn't really renal friendly but my numbers are great. Now in regards to my numbers, even though everything comes back great, I'm not anemic and still pee everything I drink with it still coming out yellow if I have let it build up a while, my creatinine is still elevated (5.?) and my BUN is still not good at 40 which shows I'm just in some stage of denial. I am accruing time on the transplant list but am not in active status until the transplant center cardiologist clears me. They wanted to wait until I have been on Plavix for a year. That's what yesterdays appointment was about.

I would like to have a transplant since it will get me off this dialysis and I could return to a traveling job up and down the coast again. I'm only 45 (well almost 46) so I intend to be here for a while and understand that in reality, whenever I do get a transplant I may get off dialysis for now but this won't be my last time having it--based on average time a transplant will last.

I guess it's time to study my options just in case but hope this is nothing major. I guess I'll find out soon.

I fear that there is a great chance of damaging your residual renal function with the angiogram. That can have significant clinical impact now and in the future. I still urinate all of my fluids that I drink, up to 2 liters a day or more. My ability to concentrate urine after 7 years is starting to dissappear but most folks don't get this long without any fluid restrictions. Salt restrictions yes, fluid no as long as I keep the salt down to a minimum.

Discuss with the transplant team what delaying the angiogram would mean in the long run. It is my impression that most transplant centers are going by time on dialysis, not time on the list. If that is true at your center, that is a very important distinction. If you have a predicted 5 year wait, ask if delaying the angiogram will impact your ability to "catch up" on the active list at a later time.

Shucks, I have seen strokes, cerebral bleeds, air embolisms, aortic perforations, renal failure, retroperitoneal fatal bleeding, arterial occusions, infections at the site of arterial puncture, heart attacks, pseudoaneurysms, and a dreaded complication called cholesterol emboli syndrome and probably some other events I don't recall at the present time. Angiograms are not to be fooled with at all especially over such a trivial criteria of a minor EKG change with no associated clinical symptoms if I read your posts correctly.

That in my mind is probably the most important question to answer. In addition, have you been following your renal function with 24 hour urines? Some people do recover even months after iodinated dye damage. Perhaps those are pertinant questions for you to discuss with your medical team.

In addition, why not start with a Thallium treadmill to get your functional capacity. Most people with stent occusions in the first year after the intervention are quite symptomatic but not always of course.

I believe if I was your doctor, I would have a whole lot of questions I would want answered by the specialists before considering an angiogram at all. The overwhelming majority of people do exceptionally well with a cardiac cath, but it is not a benign procedure at all. Proceed with due caution my friend. You have a good thing going with your urine function.

I would also add that you need to avoid undue ultrafiltration. I only pull off 300 ml of fluid with my sessions. The most I take off in-center is 500 ml. They will complain that 1200 ml is the minimum to prevent "backflush," but 1200 doesn't prevent it at all. If they insist on 1200 and you are peeing the way you state, then what I do is get 500 ml saline during treatment. I am convinced that high ultrafiltration rates reduce residual renal function prematurely, although I don't have any good study to "prove" this at this time.

From the limited information I have, those are some of the questions that I believe you should consider with your medical team. I hope this is useful information to help you discuss these issues more clearly with your team.

Best wishes,

Peter

[marlinfshr]

Thanks. You definitely bring up some points I'll discuss with my cardiologist this Thursday. Again, hopefully this is a non issue as I feel fine but I would like to be prepared.

I was still given a prescription by the transplant team for my blood work to be done, which is the first time they've wanted to have that done since my initial evaluation in August so perhaps they are planning to change my status to active now.

I also have my 3 month 24 hour urine check and regular monthly blood work to be done this week as well.

[Hemodoc]

Thanks. You definitely bring up some points I'll discuss with my cardiologist this Thursday. Again, hopefully this is a non issue as I feel fine but I would like to be prepared.

I was still given a prescription by the transplant team for my blood work to be done, which is the first time they've wanted to have that done since my initial evaluation in August so perhaps they are planning to change my status to active now.

I also have my 3 month 24 hour urine check and regular monthly blood work to be done this week as well.

No doubt I did give you a list of adverse consequences. However, angioplasty and stenting has been a Godsend to thousands of patients. If your cardiologist is concerned and he doesn't want to do a functional study first, such as Thallium treadmill or as Sestamibi, then you at least have a framework to discuss the risks, benefits and alternatives with him.

If I were in that position, I believe I would want to consider the functional test first. But review the issues with your cardiologist. I suspect that he will not readily understand how important residual renal function is for dialysis patients. I will try to post a link a bit later for you to review before your appointment.

Once again, this is just for discussion purposes to take back to your medical team.

I hope you are able to make your best decision.

Take care.

[Charlie B53]

Because of my poor kidneys my Cardiolist uses CO2 as a contrasting agent instead of dye.  I hadn't started PD then but was getting ready to.  I already had the surgical appt to have the PD cath placed.

I was surprised when the Dr explained how CO2 is used as a contrast and how the body will absorb it and just breathe it out vs a mineral that the kidneys would have to filter out to excrete.

I don't know if this can be applied to an MRI, but it wouldn't hurt to ask.

My VA Dr is also one of the department heads at the University Hospital just across the street.

[Hemodoc]

Because of my poor kidneys my Cardiolist uses CO2 as a contrasting agent instead of dye.  I hadn't started PD then but was getting ready to.  I already had the surgical appt to have the PD cath placed.

I was surprised when the Dr explained how CO2 is used as a contrast and how the body will absorb it and just breathe it out vs a mineral that the kidneys would have to filter out to excrete.

I don't know if this can be applied to an MRI, but it wouldn't hurt to ask.

My VA Dr is also one of the department heads at the University Hospital just across the street.

I haven't practiced for 7 years, but I was not aware of CO2 for cardiac cath. That is an interesting development. It was my impression that CO2 contrast was limited to below the diaphragm because of the concern over air embolism. Something else to get caught up to date. Thank you.

[Charlie B53]

Now that you mentioned below the diaphragm it may have been the Vascular Surgeon doing the stents in my illiacs that used the CO2 and not Cardio.

I don't remember, they have both had me on the table so many times and filled with that happy stuff that I just giggle and go along with whatever they want to do!  Often I just sleep thru the procedure.

I have 5 stents opening flow to both legs, I can walk with real steps instead of that old man shuffle.

Now if they could just do something for my tired butt.  I'd really feel good.

I'm beginning to remember, Cardio hung a bunch of water and ran it trying to flush me to hurry out the contrast.

[marlinfshr]

While on this subject, is the dye used in a nuclear stress test the same? I had one of them back in September for part of my transplant evaluation and that did not affect my kidneys at all. I think I remember them specifically stating that it wouldn't damage them but I don't know if it was because of a different dose or if it was a totally different dye. They are the ones who brought it up and that was my cardiologists team who did it. I wouldn't be surprised if my cardiologist wants me to do another as I would think that would be one of the tests to see if one of the arteries in my heart are really starting to get blocked again.

[Hemodoc]

While on this subject, is the dye used in a nuclear stress test the same? I had one of them back in September for part of my transplant evaluation and that did not affect my kidneys at all. I think I remember them specifically stating that it wouldn't damage them but I don't know if it was because of a different dose or if it was a totally different dye. They are the ones who brought it up and that was my cardiologists team who did it. I wouldn't be surprised if my cardiologist wants me to do another as I would think that would be one of the tests to see if one of the arteries in my heart are really starting to get blocked again.

No, it is not a dye, but instead it is a  radioactive isotope that they inject and then use a fancy gamma counter to image the radioactive blood flow going through the heart. Sounds great huh.

http://en.wikipedia.org/wiki/Radionuclide_angiography

[marlinfshr]

Thanks for the info. I wonder how many of those I need to have before I start glowing!

[marlinfshr]

Looks like I was worried over nothing. Saw my cardiologist and had another EKG done and though it was the same as a few days ago, there is nothing that concerns him as to him it is still similar to last years.
He asked if I had any questions and I replied that I was worried about needing another stent and he quickly replied "Oh Noooo!

[Hemodoc]

Looks like I was worried over nothing. Saw my cardiologist and had another EKG done and though it was the same as a few days ago, there is nothing that concerns him as to him it is still similar to last years.
He asked if I had any questions and I replied that I was worried about needing another stent and he quickly replied "Oh Noooo!

That was my suspicion. You will need to get a cardiologist at the transplant center to agree is my guess. Cardiac cath is not something you do without a really good reason. 

Good luck with all, but yes, that is good news.

[obsidianom]

The following WHOLE article is one of the best I have seen on the whole spectrum of contrast medium and kidney damage. It is worth reading .



http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3969626/